Self Referral Form

Use this service to submit your interest in receiving counselling and support from YPI Counselling. This service is primarily available to children and adults within the Basingstoke and Deane area.

Submission takes around 10 minutes.

If you need urgent help or support in a crisis

YPI is not able to offer crisis/urgent support. If you need more immediate support please consider the following:

Request an urgent appointment with your GP
Attend your local A&E department
(Under 18's) Contact Child Line on 0800 111
(Over 18's) Contact the Samaritans on 116 123

Please note we cannot work with people under an Adoption or Special Guardianship Order. Please contact Barnardo's for further information and support.

Before you start

You can also register by printing off our referral form.

You cannot register for this service if you live outside of the UK.

Start

Self Referral Form

Information about you

First Name:

Surname:

Street Address:

Town:

Postcode:

GP Surgery:

Gender:

Ethnicity:

Date of Birth

Day:

Month:

Year:

Contact information

Please provide a phone number and email address that you consent to YPI using to make and confirm appointments with you.

Name:

Phone Number:

Email Address:

Emergency contact information

Please provide a phone number for use in an emergency.

Name:

Phone Number:

Work/Education Status

School/College:

Work Status:

Living Situation:

Do you have a physical, learning or mental health condition that has been diagnosed?

Please only provide this information if you have been diagnosed by a Health Professional.

Yes

Which sexual orientation do you identify as?

Are you a parent and under 18?

Yes

Are you a young carer?

Yes

Do you suffer from poverty issues?

Yes

Are you currently in care, or under the Child Protection Plan or Child In Need Plan?

Yes

Have you ever had involvement with the Courts?

Yes

What are the main reasons you would like to have counselling support?

Have you received support in the past?

Yes

How did you hear about YPI?

Are you contacting YPI yourself?

If you are a parent or guardian completing this form on the behalf of a young person, please select yes.

Yes

By completing this form, you are giving consent to YPI to use your data for the purposes outlined in our Data Protection Statement. More information.

Contact Us

Call us on:
01256 423 878
Email us at:
office@ypicounselling.co.uk
We are open:
Mon to Fri - 9 AM to 9 PM

Portal

Self Referral Form

If you need urgent help or support in a crisis

Before you start

Self Referral Form

Information about you

Date of Birth

Contact information

Emergency contact information

Work/Education Status

Do you have a physical, learning or mental health condition that has been diagnosed?

Which sexual orientation do you identify as?

Are you a parent and under 18?

Are you a young carer?

Do you suffer from poverty issues?

Are you currently in care, or under the Child Protection Plan or Child In Need Plan?

Have you ever had involvement with the Courts?

What are the main reasons you would like to have counselling support?

Issues you would like support with:

Have you received support in the past?

How did you hear about YPI?

Are you contacting YPI yourself?

Referring Agency Information

Please acknowledge the following statement:

Please acknowledge the following statement:

Contact Us